Deerstream

Student's Name	Louis Heath Ebert
Date Of Birth	07/05/2016
T shirt size	Child M
PARENT INFORMATION
Parent 1	Martha Blankenship Ebert
Cell Phone	(919) 923-1631
Home/Work Phone	(919) 923-1631
Parent 2	Martha Blankenship Ebert
Cell Phone	(919) 923-1631
Home/Work Phone	(919) 923-1631
Emergency Contact 1	Ann Clark
Relationship	Aunt
Phone Number	(704) 293-6312
Emergency Contact 2	Benjamin Blankenship
Relationship	Uncle
Phone Number	(334) 309-7021
ALLERGY INFORMATION
Does this child have any known allergies?	No
OTHER MEDICAL INFORMATION
Physician's Name	UNC Pieds
Physician's Phone Number	919-966-6669
Preferred Medical Facility	UNC
Current Medications and Dosages	n/a
Please list any significant medical information including chronic illnesses, injuries, physical limitations, and any diagnoses this child has received.	n/a
Will your child need the learning environment or assignments adapted in any way?	No
What other information will help us to provide a safe and accessible environment for your child?	n/a
Insurance
Name of Policy Holder	Jamie Ebert
Employer	Sysco
Insurance Company	Aetna
Policy Number	0174990-015-00106
SIGNATURE	I, as parent or legal guardian, do hereby grant Deerstream faculty and trustees present the right to authorize emergency medical treatment for my child, named above, in the event that my designated representatie or I cannot be reached. I agree to hold harmless Deerstream and its agents from liability arising out of accident situations. The North Carolina Good Samaritan Law will apply.
Name	Martha Blankenship Ebert
Signature